Hamilton Animal Hospital
21552 Brookhurst St., Huntington Beach, Ca. 92646
(714) 964-4744
NEW OR RETURNING CLIENT REGISTRATION FORM
Welcome! Thank you for giving Hamilton Animal Hospital the opportunity to care for your pet.
So that we may become better acquainted, please complete the following:
( P L E A S E
P R I N T )
PRIMARY PET OWNER INFO
Pet Owner: _________________________________________________________________________________
Last,
First
MI
Home Address: _____________________________________ __________________________ _____ _______
Street Address
Apt. No.
City
Home Phone No.: (______) _______________________
State
Zip
Cell Phone No.: (______) ____________________
Employer: _____________________________________ Occupation:_____________________________
Phone No. at Work: (______)_______________________ May we call you at work if necessary?
Yes or No
Driver’s License No.: _______________________________ (please provide copy of driver’s license to receptionist)
Date of Birth: __________________ Email Address: _____________________________________________
CO-OWNER INFO
( I f
A p p l i c a b l e )
Co-Owner: _____________________________________________ Relationship to Owner: ______________
Last,
First
MI
(Not Required)
Co-Owner’s Employer: ____________________________ Co-Owner’s Occupation: _______________________
Co-Owner’s Phone No. at Work: (______) _______________________ May we call if necessary? Yes
or
No
Co-Owner’s Cell Phone: (______) _______________________
REFERRAL INFO
Who may we thank for referring you to Hamilton Animal Hospital? (check one)
Yellow Pages ______ Internet ______ Hospital Street Sign ______ Personal Recommendation ______ Other ______
__________________________________________________
Name of Individual Who Referred You (if applicable)
TELL US ABOUT YOUR PETS
(please provide any available medical records to receptionist to copy for your pet’s chart)
Pet Name
Species
Breed
Color
Birth Date
Sex
Altered
Canine/Feline/Other
M or F
Y or N
Canine/Feline/Other
M or F
Y or N
Canine/Feline/Other
M or F
Y or N
Canine/Feline/Other
M or F
Y or N
Canine/Feline/Other
M or F
Y or N
(circle one)
PAYMENT OPTIONS/INFO
It is our policy to collect fees at time of services rendered. We do not do billing. We accept the following payment types:
VISA / MASTERCARD / DISCOVER / DEBIT CARD / CHECKS / CASH
If you would like to leave a credit card number on file with us to make check out easier and more expeditious, please write credit card no. here:
_______________________________________Exp Date ___________ Card Type _____
In case of emergency hospitalization, deposit arrangements must be made prior to treatment. Upon your request, a written estimate will be provided
to you prior to treatment, providing the delay will not endanger your pet.
Signature of Owner/Co-Owner ____________________________________________ Date: _______________
Client ID No.: __________________________ (Office Use Only)